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22 Cards in this Set
- Front
- Back
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Factors that affect the accurate measurement of vital signs.
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Temp- hormone induced, circadian rhythm, spinal cord injury, fever
Blood Pressure- cardiovascular factors- hypovolumia, peripheral resistance Other factors- age, ethnicity, meds, weight BP in infants and children lower than adults Pulse Rate- exercise athletes below norm, temp febrile tachy, emotions, Drugs, hemorrhage BP drops HR increases, postural change, Pulmonary change Respirations- exercise, acute pain, anxiety, smoking, body position, meds, Neurological injury, hemoglobin function low hem faster RR Pain- acute pain will increase heart rate, BP, RR |
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Normal Ranges of Vital Signs
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Temp- 96.8-100.4
Pulse- 60-100 O2 sat- 95-100% Respirations- 12-20 BP- < 120/80 |
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Acceptable HR ranges
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Infant- 120-160 apical to 1 year
toddler- 90- 140 apical 12 months 3 years pre-schooler- 80- 110 3-5 years school aged- 75-100 5-12 years adolescent – 60- 90 12-20 years Young adult 20-40 Middle adult 40-60 Adult- 60- 100 |
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Tachycardia
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Greater than 100 beats per minute
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Bradycardia
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Below 60
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Infant
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Apical pulse- 120-160
Respirations- 30-60 Temp- 95.9- 99.5 |
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PreHyper tension
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pre-120-139 over 80-89
Stage 1 Hypertension-140-159 over 90-99 Stage 2 Hypertension-160 and up over 100 & up |
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Two factors influencing body heat production
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Basal metabolic rate- heat produced while body is at rest
Voluntary movement- muscular activity Muscle shivering |
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Two ways body loses heat
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Radiation- one object to another without contact
Conduction- one object to another with contact Convection- by air Evaporation- by bathing Diaphoresis- profuse sweating |
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Bodies temp regulation center
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Posterior hypothalamus- controls heat production
Anterior hypothalamus- controls heat loss |
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Methods for measuring body temp
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Oral- easily accessible/ not for children
Tympanic- used on children, not as accurate Axillary- varies with heat loss, 1 degree less than oral Rectal- 1 degree higher than oral |
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Alterations of body temp and appropriate nursing care for each.
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Pyrexia/ fever
Fever of unknown origin (FUO) Hyperthermia- excessively high temp Hypothermia- low temp |
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Indications and contraindications for each of the various methods for assessing temp.
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oral advantages- easily accessible, accurate temperature, assesses rapid change, reliable in intubated clients
Limitations: no food, drink, or smoking 30 min prior, not for infants or unconscious clients Tympanic advantages: easily accessible reading of core temp, not affected by food or drink, can be used on infants Limitations: no continuous measurement, inaccuracies possible due to faulty positioning Rectal advantages: more reliable when oral temp cannot be obtained. Limitations: embarrassing and uncomfortable, requires repositioning and lubrication. Axillary advantages: safe, inexpensive, use in newborns and unconscious clients. Limitations: long measurement time, requires exposure Skin advantages: continuous reading, safe, used for neonates Limitations: adhesion impaired by sweat, adhesion allergies, doesn’t detect rapid changes Temporal advantages: easy access, rapid measurement, no risk of exposure, detects rapid change in core temp Limitations: affected by skin moisture, no continuous measurement |
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Nine pulse sites and reasons for their use.
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Temporal: easily accessible, used for children
Carotid: accessible during shock/cardiac arrest Apical: auscultate for apical pulse Brachial: assess circulation to lower arm, auscultate blood pressure Radial: assess circulation to hand Ulnar: assess circulation to hand, perform Allen’s test (compression on ulner artery) Femoral: assess circulation to leg and during shock/cardiac arrest Popliteal: assess circulation of lower leg Posterior tibial: assess circulation of the foot Dorsalis pedis: assess circulatio of the foot |
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Characteristics to be assessed in a pulse
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Rate, rhythm, strength, equality
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How to assess both apical and radial pulses
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Apical: requires stethoscope, auscultate between fourth and fifth intercostal space at left midclavicular line
Radial: Palpate radial artery at the wrist |
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Describe the mechanics of breathing and the mechanisms of respiratory control.
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Inspiration is active, expiration is passive. Abdominal organs move downward and forward with inspiration
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Identify the characteristics that should be included in a respiratory assessment
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Rate, pattern, depth, saturation, ventilation, diffusion, and perfusion
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Differentiate between systolic and diastolic BP
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Systolic is BP during contraction, diastolic is BP during relaxation.
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Describe various methods and sites used to measure BP
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Noninvasive – use sphygmomanometer and stethoscope or sphyg and palpation; upper limb or lower limb if upper limb not accessible
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Invasive
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insertion of central line
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Which method of taking temperature is the least invasive?
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Temporal
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